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Kurt Cobain wrote "Heart-Shaped Box" in early 1992.[4] Cobain forgot about the song for a while, but began working on it again when he and his wife, Courtney Love, moved to a house in the Hollywood Hills.[5] In a 1994 Rolling Stone interview, Love said she overheard him working on the song's riff in a closet. She said she asked him if she could use the riff for one of her songs, to which he replied, "Fuck off!" and closed the closet door. "He was trying to be so sneaky", said Love. "I could hear that one from downstairs."[6] The couple shared a journal in which they would write lyrics; Cobain biographer Charles R. Cross noted that Love's songwriting sensibility informed Cobain's on the song.[7] The song's name came from a heart-shaped box Love had given Cobain. However, Cobain had originally titled the song "Heart-Shaped Coffin".[7]

Nirvana had difficulty completing the song. Cobain attempted to have the rest of the band complete the song during jam sessions. He said, "During those practices, I was trying to wait for Krist and Dave to come up with something but it just turned into noise all the time." One day Cobain made one last attempt at completing the song. Cobain was able to come up with a vocal melody and the band finally finished writing the song. Cobain said that when they completed "Heart-Shaped Box", "We finally realized that it was a good song."[8]

In January 1993, the band recorded a demo of "Heart-Shaped Box" during sessions with Craig Montgomery in Rio de Janeiro, Brazil; it was the first song recorded.[9] The In Utero version was recorded in February 1993 by Steve Albini in Cannon Falls, Minnesota. Prior to the album's release, the track was remixed by Scott Litt. Cobain was unapologetic about the band's decision to remix it, and maintained that the vocals and bass were not prominent enough in the original mixes. Nirvana bassistKrist Novoselic was also unhappy with the original mix of "Heart-Shaped Box". In a 1993 Chicago Sun-Times interview, he said the original effect used on the song's guitar solo sounded "like a fucking abortion hitting the floor." When the song was remixed by Litt, Cobain took the opportunity to add acoustic guitar and backing harmonies.[10]

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"Heart-Shaped Box", released as the first single from In Utero, was augmented during mixing sessions with Scott Litt. Displeased with the sound of the song, Nirvana had Litt increase the volume of Cobain's vocals and the bass guitar, and the group added acoustic guitar and backing vocals.

Journalist Gillian Gaar described "Heart-Shaped Box" as "the Nirvana formula personified, with a restrained, descending riff played through the verse, building in intensity to the cascading passion of the chorus".[4]

Cobain said the song was inspired by documentaries about children with cancer. He told biographer Michael Azerrad, "Anytime I think about it, it makes me sadder than anything I can think of."[11] Azerrad asserted in his biography Come as You Are: The Story of Nirvana that despite Cobain's explanation, the song actually appeared to be about Courtney Love.[8] Charles Cross wrote in his Kurt Cobain biography Heavier Than Heaven that with the lyric "I wish I could eat your cancer when you turn black", the frontman "sang in what has to be the most convoluted route any songwriter undertook in pop history to say 'I love you'".[12] After a performance of the song by singer Lana Del Rey, in 2012 Courtney Love asserted on Twitter that the song was about her vagina. The tweets were deleted shortly after.[13] Cobain said that the song's chorus of "Hey/Wait/I've got a new complaint" was him giving an example of how he was perceived by the media.[14]

In the United States, DGC issued "Heart-Shaped Box" to college, modern rock, and album-oriented rock radio stations in early September 1993. There were no plans to release a single for the song domestically. At the time, Geffen Records' head of marketing told Billboard that the label was not actively courting Top 40 radio, explaining "Nirvana didn't sell nearly 5 million [records] because of a hit single. They sold that many albums because of who they are." The song entered the Billboard Modern Rock Tracks chart at number seven,[15] and eventually peaked at number one on the chart.[1] The song also reached number four on the Mainstream Rock Tracks chart.[16] A single of the song was released in the United Kingdom, where it peaked at number five on the UK Singles Chart.[2][3] Issued in August 1993, the 7-inch vinyl and cassette formats featured "Marigold" as a B-side, while the 12-inch vinyl and CD editions added the In Utero track "Milk It".[17] In 1999 the song was voted in at number 10 in Kerrang! magazine's "100 Greatest Rock Tracks Ever!".[18]

Nirvana originally wanted Kevin Kerslake, who had directed the videos for the band's singles "Come as You Are", "Lithium", "In Bloom", and "Sliver", to direct the "Heart-Shaped Box" music video. Kerslake prepared five treatments during July and August 1993, but no shoot arrangements were made and by the end of the month, the group decided to work with Dutch photographer and video directorAnton Corbijn.[19] Corbijn, who typically created his own ideas for videos, was initially unsure of directing the video since Cobain's treatment was so detailed. Corbijn said, "But then I looked at it and I thought that actually it was pretty good. I was very amazed by somebody writing a song and having those ideas as precise as he did."[20]

The video begins and ends with the band in a hospital setting watching an old man being administered medication through an IV drip. The majority of the video takes place in a surreal outdoor setting that incorporates imagery from the film The Wizard of Oz.[21] During the song's first verse, the old man from the hospital climbs onto a crow-ridden Christian cross. The second verse introduces a young girl in a white robe and peaked cap reaching for human fetuses in a tree, and an overweight woman in a suit with human organs painted onto it and with angel wings affixed to her back. In the video's final cut, the band is only shown performing in the outdoor setting during the choruses, where Cobain's face moves in and out of focus in the camera.[21] While most of the video was devised by Cobain, Corbijn added elements such as the intentionally artificial crows, a ladder for the old man to climb onto the cross with, and a box with a heart at the top that the band performs inside of during the song's final chorus.[22] Corbijn created another cut of the video featuring alternate footage during the final verse, including more shots of the young girl and the woman, and scenes of Cobain lying on his back in the poppy field, with mist surrounding him. This version of the video is featured on the DVD The Work of Director Anton Corbijn.[23][24]

After the video's release, Kevin Kerslake sued Nirvana, alleging copyright infringement. The case was settled out of court.[25] The video won two MTV Video Music Awards in 1994, for Best Alternative Video and for Best Art Direction. As the ceremony was held after Kurt Cobain's April 1994 death, the awards were accepted by Cobain's former bandmates Novoselic, Grohl, and touring guitarist Pat Smear.[26] "Heart-Shaped Box" also topped the music video category in the 1993 Village VoicePazz & Jop critics' poll.[27] In 2011, NME ranked the song's music video at number 22 on its of the "100 Greatest Music Videos".[28] That same year, Time magazine included "Heart-Shaped Box" on its list of "The 30 All-TIME Best Music Videos", where it was described as "beautiful and [...] terrible".[29]